Provider credentialing helps healthcare facilities to hire qualified physicians with high standards of care and professionalism. Qualified practitioners reduce malpractice cases, protect the reputation of healthcare institutions, and boost patient confidence in the quality of medical care. Here’s an in-depth look at credentialing and why it’s necessary:
What Is Provider Credentialing?
Provider credentialing is the process of assessing and verifying providers’ qualifications and professional backgrounds. Qualifications typically reviewed in the credentialing process include medical training, licensing, and certification. A professional background is conducted to understand a provider’s work history and identify malpractice claims and any disciplinary actions. The primary goal of credentialing is to determine the competency of healthcare professionals. This process determines whether a healthcare organization hires the applicant under assessment.
The credentialing process typically involves the following steps:
- Application: A healthcare provider provides detailed personal and professional information like their name, educational background, certifications, and references. Providers only need to provide such information when applying for a desired position.
- Verification: The healthcare organization that receives the application reviews the information provided. Verification may involve contacting educational institutions, professional organizations, and licensing boards. Doing so allows the organization to confirm the authenticity and accuracy of the information provided.
- Background check: This involves checking for criminal history, malpractice claims, or disciplinary actions that can impact the healthcare provider’s suitability for the open position.
- Peer review: This involves assessing a provider’s past performance. The healthcare organization can collect feedback from the provider’s past colleagues and patients. This information helps in gauging their professionalism and clinical skills.
- Decision-making: The healthcare organization decides whether to hire the provider based on their findings.
- Privileging: If approved, the healthcare organization grants the provider privileges, specifying the scope of their practice within the organization.
These steps may vary depending on a healthcare organization’s hiring guidelines. Some organizations work with professional provider credentialing services to limit the burden of credentialing and enhance accuracy.
Why Is Credentialing Necessary?
Credentialing is beneficial for the following 5 reasons:
1. High-Quality Patient Care and Enhanced Patient Safety
Providers with all the necessary training and certifications have the expertise to offer quality patient care. Credentialing allows healthcare institutions to identify these professionals, reducing the risk of substandard care.
Credentialing also reveals a provider’s detailed work history, allowing healthcare organizations to assess clinical competence and past medical errors, if any. Identifying past malpractice claims can save an organization from hiring providers with questionable medical practices, creating a safer practice environment.
2. Regulatory Compliance
Bodies like the Centers for Medicare & Medicaid Services (CMS) and the Joint Commission require medical institutions to hire qualified providers. Credentialing helps medical institutions comply with the requirements imposed by these bodies. This can present benefits like a reduced risk of penalties and continued certification from the Joint Commission.
3. Risk Management
Credentialing can help healthcare organizations identify providers with a history of legal or ethical issues. This can facilitate informed decision-making on whether to affiliate with such providers, minimizing the risk of future lawsuits.
4. Insurance Network Participation
Many insurance companies require providers to undergo credentialing before they can participate in their networks. They impose this requirement to make sure providers are qualified to provide quality patient care. Credentialing allows healthcare organizations and providers to receive reimbursement for their services.
5. Patient Trust
Effective credentialing can enhance patients’ trust in a healthcare organization. Patients will likely have greater confidence in their care when they know their chosen medical institution has a rigorous credentialing process. This process assures them that their healthcare providers have the necessary skills to provide efficient care.
What Are Some Credentialing Best Practices?
Implementing credentialing best practices can help speed up the process without compromising the quality of its results. Here are some best practices to consider:
- Start early: Don’t wait until there’s an urgent need for a provider to start the credentialing process, as you may have to cut some corners. Starting early can allow you to conduct a thorough background check and give you time to talk to a provider’s peers.
- Use standardized credentialing application forms: Choose forms that collect comprehensive information on providers’ personal and professional information. Getting all the information you need at once can facilitate easier review.
- Develop clear credentialing policies: Establish well-defined policies that outline your organization’s credentialing process. Developing clear guidelines can promote consistency and efficiency throughout the process.
- Outsource the process: Hiring an experienced credentialing firm can free your staff up to perform other tasks. Look for a firm specializing in provider credentialing, as they’ll likely know what to assess.
Provider Credentialing Is Necessary
Provider credentialing can help healthcare organizations create a safe environment focused on patient well-being. The credentialing process can also reduce the burden of decision-making when hiring, as it allows qualified providers to stand out from the rest. It’s a worthwhile investment for any organization looking for competent healthcare providers.